Vesicourethral Dysfunction Following Radical Surgery for Rectal Carcinoma: Change in Voiding Pattern on Sequential Urodynamic Studies and Impact of Nerve-Sparing Surgery

Objectives Urodynamic studies were performed to clarify vesicourethral dysfunction and recovery after rectal surgery for cancer.
Materials and Methods At 1, and 6 to 12 months after rectal surgery interviews and urodynamic studies (UDS) were performed on 51 consecutive patients, all without a prior history of voiding disorder (40 males and 11 females; median age, 60 years). Patients were divided into 2 groups, either with (preserved group, n = 17) or without (nonpreserved group, n = 34) preservation of the bilateral pelvic plexus during surgery. Comparisons of voiding status and urodynamic parameters were made between the 2 groups.
Results By 1 and 6 months after the operation normal voiding was achieved in 71 % (12/17) and 100% (13/13) of patients in the preserved group, and 6% (2/34) and 30% of patients (9/30) in the nonpreserved group, respectively (P< 0.001). Attainment of normal voiding in the nonpreserved group was preceded by the recovery of bladder sensation, while UDS demonstrated increases in vesical compliance and the disappearance of vesical denervation supersensitivity.
Conclusion A nerve-sparing procedure during radical surgery for rectal carcinoma preserved vesicourethral function. The urodynamic parameters relevant to postoperative recovery of voiding function were improved vesical compliance, disappearance of vesical denervation supersensitivity, and recovery of a bladder filling sensation.     

直肠癌TME中保留盆腔自主神经对男性排尿及性功能影响的初步研究

目的:探讨保留盆腔自主神经(pelvic autonomic nerve preservation,PANP)的直肠全系膜切除术(total mesorectal excision,TME)对男性排尿及性功能的影响.方法:对2005～2006年48例进行丁ME(对照组)和2007～2008年进行PANP+TME的53例(治疗组)男性直肠癌患者的排尿及性功能情况进行回顾性分析.结果:术后勃起功能障碍的发生率为治疗组28.30%(15/53),对照组72.92%(35/48),2组差异有统计学意义(P<0.001);射精功能障碍的发生率为治疗组24.53%(13/53),对照组62.50%(30/48),2组差异有统计学意义(P=0.001);排尿障碍的发生率为治疗组18.87%(10/53),对照组47.92%(23/48),2组差异有统计学意义(P<0.001).结论:PANP和TME结合可以明显改善患者的排尿功能和性功能,从而提高患者术后生活质量.     

Preliminary results of a monitoring system to confirm the preservation of cavernous nerves

BACKGROUND: It is important to preserve the neurovascular bundle (NVB) during nerve-sparing surgery. This article presents the preliminary results of our monitoring system for the postoperative preservation of erectile function. METHODS: In 15 patients undergoing radical prostatectomy and 20 patients undergoing radical cystoprostatectomy, intraoperative electrical stimulation along the NVB was performed to measure changes in intracavernous pressure before and after prostate removal. Seven of the radical prostatectomy patients and eight of the radical cystoprostatectomy patients underwent nerve-sparing surgery. Postoperative erectile function was evaluated in 25 patients not receiving adjuvant hormonal therapy. RESULTS: The NVB was judged to be preserved at least on one side electrophysiologically in 14 of 15 patients. Pathologically, three patients had pT3 cancer. Postoperatively, sufficient erectile function was demonstrated using the International Index of Erectile Function 5 in three patients, nocturnal penile tumescence in three patients, and a questionnaire or an interview in three patients. The other patients were incompletely erectile. None of the 11 patients not receiving adjuvant hormonal therapy, in whom NVB was not preserved, were erectile. CONCLUSION: If the successful criterion of nerve-sparing surgery is defined as a change in intracavernous pressure of 4 cm H2O or more being observed at least unilaterally, and the successful criteria of erectile function preservation includes being sufficiently erectile as revealed by an interview, the sensitivity of our system was 69.2% (9/13) and the specificity was 100% (12/12). Neither adverse reactions to the measurement, nor inadequacy of cancer excision accompanying NVB sparing, were observed. These results suggest that our system can predict postoperative erectile function fairly accurately.     

Urogenital function 3 years after abdominoperineal excision for rectal cancer

Aim

The aim of this study was to explore urogenital dysfunction and associated risk factors after treatment of rectal cancer, in a large national cohort of patients 3 years after abdominoperineal excision, and to compare outcomes with a reference population and a cohort of patients operated for prostate cancer.

Method

Patients treated with abdominoperineal excision in 2007–2009 were identified using the Swedish Colorectal Cancer Registry. All consenting patients received a questionnaire. A sample of the Swedish population was contacted and completed a questionnaire. Patients undergoing radical prostatectomy in a prospective multicentre trial received questionnaires 24 months after surgery.

Results

In the abdominoperineal excision, reference and radical prostatectomy populations 72%, 51% and 91% of the questionnaires were returned. Within the abdominoperineal excision group 36% of the men and 57% of the women were incontinent postoperatively. Fifteen per cent and 37% of men and women in the reference group were incontinent. Two years after radical prostatectomy 49% were incontinent. Seventy‐four per cent of the men had erectile dysfunction after abdominoperineal excision. Nineteen per cent of the women experienced reduced ability to reach orgasm. Fewer men and women experienced their present sex life as satisfying after abdominoperineal excision for rectal cancer compared with the reference population.

Conclusion

A large proportion of patients endure persistent urogenital dysfunction after abdominoperineal excision for rectal cancer as do men after radical prostatectomy. Effects on sexual and urinary function should be part of preoperative information and after surgery patients should be asked about function in order to identify those in need of further assistance.     

Effect of radical retropubic prostatectomy on erectile function, evaluated before and after surgery using colour Doppler ultrasonography and nocturnal penile tumescence monitoring

OBJECTIVE: To assess the effect of radical retropubic prostatectomy on erectile function, by evaluating objectively patients' erectile function before and after surgery. PATIENTS AND METHODS: The study comprised 126 patients with clinically localized prostate cancer who were scheduled to undergo radical retropubic prostatectomy. After giving informed consent for the study, 123 patients underwent intracavernosal injection tests, colour Doppler ultrasonography and nocturnal penile tumescence monitoring before and after surgery. RESULTS: From the intracavernosal injection tests and nocturnal penile tumescence monitoring, 21 patients (17%) were evaluated as having normal erectile function before surgery. After radical retropubic prostatectomy, nine (43%) of these 21 potent men had preserved erectile function. In eight patients whose neurovascular bundles were preserved, five were potent after surgery. The cause of erectile function after surgery was a neurogenic disorder in seven and a related vascular disorder in five. CONCLUSION: From objective tests of erectile function on patients scheduled to undergo radical prostatectomy, 17% had normal erectile function. However, even after nerve-sparing radical retropubic prostatectomy, the proportion retaining potency was unsatisfactory. Although a neurological disorder was the main cause of erectile dysfunction after surgery, vascular disorders were also important.     

Major urinary dysfunction after mesorectal excision for rectal carcinoma

BACKGROUND: Urinary dysfunction may occur after mesorectal excision and pelvic autonomic nerve preservation (PANP) in patients with rectal carcinoma. The aim of this prospective study was to identify factors predictive of long-term urinary catheterization. METHODS: Two hundred and ten patients without significant urological problems underwent resection of rectal cancer with mesorectal excision. The number of patients with complete, partial or no identification of the nerves was documented and correlated with possible predictive factors for postoperative major urinary dysfunction. RESULTS: Eight patients (3.8 per cent) required long-term urinary catheterization: two after complete PANP (two of 168) and six in whom PANP was incomplete (six of 42) (P = 0.001). Multiple regression analysis identified incomplete PANP (odds ratio 13.8 (95 per cent confidence interval 2.7 to 71.3); P = 0.002) as a predictive factor for major urinary dysfunction. CONCLUSION: Major urinary dysfunction after mesorectal excision for rectal cancer is associated with an incomplete nerve-sparing technique.     

Recovery of sexual function after nerve-sparing radical prostatectomy or cystectomy

BACKGROUND: The recovery of sexual function (erectile function and frequency of sexual intercourse) over time after nerve-sparing radical prostatectomy or cystoprostatectomy was evaluated. METHODS: Forty-nine consecutive patients with clinically localized prostate cancer and muscle-invasive bladder cancer were treated with radical prostatectomy and radical cystoprostatectomy with a nerve-sparing procedure. Erectile function was evaluated by the circumferential change of the penis during nocturnal penile tumescence (NPT value) with an erectometer before and after surgery. Erectile function and the frequency of sexual intercourse were also evaluated with a self-administered questionnaire before and after surgery. Multivariate analysis by Cox's proportional hazards model was used to evaluate the factor(s) that affected the recovery of erectile function and sexual intercourse. RESULTS: The recovery rates of erectile function were 49% at 3 years and 79% at 5 years. For recovery of sexual intercourse the rates were 36% at 3 years and 57% at 5 years. Multivariate analysis revealed that the preoperative NPT value was the only independent factor which significantly affected the recovery of erectile function. The age at surgery was a significant factor for recovery of sexual intercourse. CONCLUSION: Nerve-sparing operations can often, but not always, provide preservation or recovery of erectile function for patients who receive radical prostatectomy or cystoprostatectomy. Recovery of erectile function depends upon the preoperative NPT value and recovery of sexual intercourse depends upon the age of the patient.     

The indications for autonomic nerve-sparing surgery in rectal cancer patients

Although extended lymph node dissection was developed to improve the therapeutic result in advanced rectal cancer in the 1970s, postoperative dysfunction remained problematic. Informed consent of cancer is generalized at present. The balance between complete cure and functional preservation is important. Therefore the autonomic nerve-sparing surgical technique for rectal cancer was introduce din the 1980s. The success of nerve-sparing surgery depends on a thorough knowledge of pelvic anatomy, especially the anatomic relationship between the pelvic plexus and internal intestinal vessels. Further investigation is required to clarify the indications for autonomic nerve-sparing surgery in rectal cancer patients.     

Autonomic nerve-sparing surgery combined with preoperative radio-chemotherapy in advanced lower rectal cancer patients

Since 1985, we have studied autonomic nerve-sparing surgery combined with preoperative radiochemotherapy in patients with advanced rectal cancer to preserve genitourinary function without compromising radicality. The aim of this study was to evaluate postoperative genitourinary function and prognosis. A total of 84 patients with advanced rectal cancer underwent curative surgery combined with preoperative radio-chemotherapy. Of them, 76 underwent curative nerve-sparing surgery using radiation (42.6 Gy) and tegafur suppository. Postoperative genitourinary function, survival, and pelvic recurrence were investigated in these patients. The 5-year and 10-year disease-free survival rate was 80.7%, and the pelvic recurrence rate was 7.9% in patients receiving curative nerve-sparing surgery combined with radio-chemotherapy. All of these patients could micturate spontaneously, but preservation of sexual function was not as successful. Although this combined therapy is useful for curability and good postoperative quality of life, a new approach is needed to preserve sexual function.     

直肠癌手术对男性性功能和排尿功能的影响

目的　研究直肠癌患者术后性功能和排尿功能的变化。方法　对我院 79例直肠癌患者通过调查的方式调查术后性功能和排尿功能情况 ,并按年龄、术式进行回顾性分析。结果　性功能障碍小于 40岁患者为 3 7.5 % ,40 -5 9岁为 60 .4% ,大于 60岁为 95 .7%。Miles术后并发性功能障碍为 80 .5 % ,近期排尿困难为 46.3 % (1 9 41 ) ,远期排尿困难为 4.9% (2 41 ) ;Dixon术后并发性功能障碍5 5 .3 % ,近期排尿困难为 2 8.9% (1 1 3 8) ,无远期排尿困难。结论　男性直肠癌患者术后性功能和排尿功能障碍发生率高。手术时患者的年龄和手术方式对其发生率有直接影响。保留植物神经的直肠癌根治术可有效地减少患者术后性功能和排尿功能障碍     

Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery.

BACKGROUND: The introduction of total mesorectal excision (TME) has been shown to improve local recurrence rates in rectal cancer. The present study investigated the impact of this more extensive and radical procedure with regard to autonomic pelvic nerve function. METHODS: Patients with resected primary rectal cancer were interviewed by means of a questionnaire asking about preoperative and postoperative urinary bladder and genital function. The results in patients after rectal cancer surgery without TME (group 1; n = 29) were compared with those obtained after introduction of the TME technique (group 2; n = 31). Patients in group 2 were older and had a lower level of anastomosis than patients in group 1. Other patient, treatment and tumour characteristics were comparable between the groups. RESULTS: : Newly acquired and permanent symptoms of bladder dysfunction after rectal excision were present as follows (group 1 versus group 2): difficulty in bladder emptying 7 versus 19 per cent; sensation of incomplete bladder voiding 17 versus 17 per cent; urgency 17 versus 14 per cent; incontinence 10 versus 3 per cent; dysuria 7 versus 7 per cent; and dribbling 14 versus 8 per cent. Male patients stated the following sexual functions before operation/after operation in group 1 versus group 2: interest in sex 80 per cent/40 per cent versus 63 per cent/37 per cent; sexually active 67 per cent/7 per cent versus 53 per cent/22 per cent; impotence 75 per cent/6 per cent versus 58 per cent/26 per cent; ability to have intercourse 75 per cent/13 per cent versus 67 per cent/29 per cent; ability to achieve orgasm 88 per cent/13 per cent versus 76 per cent/47 per cent; and orgasm with ejaculation 88 per cent/9 per cent versus 76 per cent/53 per cent. CONCLUSION: While both conventional rectal cancer surgery and TME result in similarly favourable postoperative bladder function, both techniques decrease sexual function. However, TME offers a significant advantage with regard to preservation of postoperative sexual function in men and constitutes a true advance in rectal cancer surgery compared with conventional techniques.     

Nerve-sparing open radical retropubic prostatectomy

INTRODUCTION: In recent years, the surgical technique for open radical prostatectomy has evolved and increasing attention is paid to preserving anatomic structures and the impact on outcome and quality of life. METHODS: Technical aspects of nerve-sparing open radical retropubic prostatectomy (RRP) are described. Patient selection criteria and functional results are discussed, focusing on postoperative urinary continence. RESULTS: The video demonstrates the nerve-sparing open RRP and important steps are elucidated with schematic drawings. The value of nerve sparing, not only for preserving erectile function, but also for preserving urinary continence is discussed and results from our institution are presented. In our series, urinary incontinence was present in 1 of 71 patients (1%) with attempted bilateral nerve-sparing, 11 of 322 (3%) with attempted unilateral nerve-sparing, or 19 of 139 (14%) without attempted nerve-sparing surgery. In multiple logistic regression analysis, the only statistically significant factor influencing urinary continence after open RRP was attempted nerve sparing (odds ratio, 4.77; 95% confidence interval, 2.18-10.44; p=0.0001). CONCLUSIONS: Nerve-sparing surgery has a significant impact on erectile function and urinary continence and should be performed in all patients provided radical tumour resection is not compromised. For successful nerve preservation we advocate a lateral approach to the prostate to improve visualisation and simplify separation of the neurovascular bundles from the dorsolateral prostatic capsule. Bunching, ligating, and incising Santorini's plexus over the prostate and not over the sphincter ensures a bloodless surgical field. Mucosa-to-mucosa adaptation of the reconstructed bladder neck and the urethra is another important factor to be observed.     

Sexual function before and after radical retropubic prostatectomy: A systematic review of prognostic indicators for a successful outcome

OBJECTIVES: Erectile dysfunction is common after surgery for prostate cancer. Potency rates after radical retropubic prostatectomy (RRP) vary widely among different studies. Since the introduction of the nerve-sparing technique potency rates have increased. Erectile function recovery rates for selected groups of patients are high. However, studies from community practices have shown less favourable outcomes after RP. METHODS: We have performed a systematic review of the literature concerning sexual function after RRP and focused on prognostic indicators for a successful sexual outcome. RESULTS: Most important prognostic factors for the return of potency after RRP are preservation of the neurovascular bundles, age of the patient and sexual function before the operation. Neurogenic and vasculogenic factors seem to play an important role in the aetiology of the erectile dysfunction after surgery. The role of preserving the accessory pudendal artery is not certain, although some investigators found significant hemodynamic changes after sacrificing the accessory pudendal artery. Colour Doppler ultrasound studies in combination with intracavernous injection of vasoactive drugs or after PDE-5 inhibitors administration has shown to be a reliable test for vascular factors. CONCLUSIONS: After bilateral nerve-sparing RRP sexual potency is preserved in 31-86% of sexually active men with organ-confined disease. The aetiology of impotence following RRP is multifactorial, but neurogenic factors seem to play a major role. Vascular factors may be of importance in selective cases. Colour Doppler ultrasound appears to be the most reliable, non-invasive diagnostic test for erectile dysfunction after RRP in patients who do not respond to pharmacotherapy.     

Rehabilitative therapy for erectile function after nerve-sparing radical prostatectomy

BackgroundTo date, the time course for recovery of erectile function and the effect of rehabilitative treatment after nerve-sparing radical prostatectomy (RP) is still under debate. The aim of this study was to evaluate the effect of low-dose sildenafil for rehabilitation of erectile function after nerve-sparing RP.MethodsIn a prospective, randomised study, 43 sexually active patients underwent a nerve-sparing retropubic RP. Erectometer measurement of nocturnal penile tumescence and rigidity (NPTR) was carried out 7–14 days after surgery. Some patients (23) with preserved nocturnal erections received sildenafil 25 mg/day at night to support recovery of erectile function. A control of 18 patients underwent follow up without phosphodiesterase type 5 (PDE-5) inhibitors. The International Index of Erectile Function (IIEF-5) questionnaire was given 6, 12, 24, 36, 52 and 78 weeks after operation.ResultsA total of 41 out of 43 patients (95%) showed 1–5 erections during the first night after catheter removal. In the daily sildenafil group, the IIEF-5 score decreased from a preoperative mean score of 20.8 to mean scores of 3.6 at 6 weeks, 3.8 at 12 weeks, 5.9 at 24 weeks, 9.6 at 36 weeks, 14.1 at 52 weeks and 19.4 at 78 weeks after prostatectomy. In the control group, the preoperative IIEF-5 mean score of 21.2 decreased to 2.4 at 6 weeks, 3.8 at 12 weeks, 5.3 at 24 weeks, 6.4 at 36 weeks, 9.3 at 52 weeks and 13.4 at 78 weeks. Statistical evaluation showed a significant difference in IIEF-5 score and time to recovery of erectile function between the groups (p<0.001) with potency rates of 92% vs. 68%.ConclusionsIn this study of men, the measurement of NPTR after nerve-sparing RP showed erectile function even during the “first” night after catheter removal. Sildenafil was efficacious when used in a “daily low dose” treatment and led to a significant improvement in recovery of erectile function.     

Contemporary cystectomy and urinary diversion

Radical cystectomy has emerged as the standard therapy for patients with invasive bladder cancer. Controversy is related to the indication, i.e. a low or high threshold. Meticulous pelvic lymphadenectomy can cure 20%-30% of patients with lymph node metastases, particularly those with limited node involvement. Unilateral nerve-sparing surgery is feasible in most patients without compromising oncological outcome and, besides erectile function, has an impact on the continence status after orthotopic bladder substitution. The excellent local control rates following radical cystectomy indicate that the weight of the problem in the future lies in reducing distant metastases. Orthotopic bladder substitution with a low-pressure ileal reservoir is currently the preferred method to reconstruct the lower urinary tract for both sexes following cystectomy. Long-term experience with follow-ups exceeding 10 years demonstrates a sustained favourable voiding outcome with slightly increasing incontinence rates as patients age.     

腹腔镜下PANP+TME与TME对男性直肠癌术后排尿、性功能的保护效果研究

目的探讨腹腔镜下保留盆腔自主神经(PAN)的全直肠系膜切除术(TME)对男性直肠癌术后排尿、性功能的保护效果。方法前瞻性纳入2018年1月至2019年12月行腹腔镜TME的男性直肠癌患者98例,随机数字法分为:对照组和PANP组各49例。对照组不保留PAN,PANP组保留PAN。采用软件SPSS 22.0处理数据,围手术期指标等计量资料以(x±s)表示,行独立样本/检验;排尿、勃起、射精功能障碍情况等计数资料行χ²检验,排尿、勃起、射精功能分级等等级计数资料行秩和检验;生存分析采用Kaplan-Meier法并行Log-rank检验。P<0.05表示差异有统计学意义。结果与对照组比,PANP组患者术后肠鸣音恢复时间、排气时间及住院时间均显著缩短,淋巴结清扫枚数显著增加(P<0.05);而手术时间及术中出血量比较,差异无统计学意义(P〉0.05);PANP组患者术后排尿、勃起及射精功能均显著优于对照组(P<0.05),且术后排尿、勃起及射精功能障碍发生率较对照组均明显降低,差异均有统计学意义(P<0.05);对照组与PANP组患者的累积无病生存率(85.7% vs 93.9%)比较,差异无统计学意义(P=0.204)。结论腹腔镜下PANP+TME不仅能使患者早日康复,而且对患者术后排尿、性功能也具有更好的保护效果,值得临床推广应用。     

Urinary continence and erectile function: a prospective evaluation of functional results after radical laparoscopic prostatectomy

OBJECTIVES: To evaluate prospectively functional results (urinary continence and erectile function) after laparoscopic radical prostatectomy. METHODS: From 1998 to 2001, 235 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. All of them completed a confidential, self-administered questionnaire regarding urinary continence and erectile function before, and 1, 3, 6, and 12 months after surgery. Results were analyzed separately for day and night for urinary continence and status of neurovascular bundles as well as age for erectile function. RESULTS: To date, 100 consecutive patients have completed all questionnaires. Diurnal and nocturnal urinary continence have increased to 90% and 97% one year after surgery. Overall, 49.3% of the 77 patients, who were potent preoperatively, and did not receive any form of adjuvant therapy, had erections sufficient for intercourse one year after surgery. Potency rates were 38.4%, 53.8% and 58.8% after no, unilateral, and bilateral nerve bundle preservation, respectively. For younger patients (<60 years) with unilateral and bilateral neurovascular bundle preservation, potency rates were 75% and 83.3%, respectively. CONCLUSION: One year after laparoscopic radical prostatectomy, urinary continence rate is 90% during the day and 97% during the night. Overall potency rates after bilateral preservation of neurovascular bundles are 58.8% and 83.8% for the subgroup of younger patients (<60 years).     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate erectile dysfunction (ED), 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

低位直肠癌保留神经的腹膜外侧方扩大清扫的效果分析

目的 探讨低位直肠癌保留神经的腹膜外侧方扩大清扫对患者术后生存率、排尿功能和性功能的影响。方法 回顾性分析我院1996年1月至2000年6月期间收治的392例进展期低位直肠癌实施保留神经的根治性切除术患者的临床资料，其中行腹腔内清扫173例，腹腔内加腹膜外侧方清扫219例，2组患者在年龄、性别、浸润肠壁深度及肿瘤病理组织学类型方面差异无统计学意义。结果 腹腔内加腹膜外侧方清扫组侧方淋巴结转移率为17．8％（39／219），侧方盆壁非连续性癌灶转移率为5，9％（13／219）。术后发生排尿功能障碍：腹腔内清扫组7例（4．0％），腹腔内加腹膜外侧方清扫组113例（51．6％），2组比较差异有统计学意义（P〈0．01）；性功能障碍：腹腔内清扫组93例男性患者中有12例（12．9％），腹腔内加腹膜外侧方清扫组119例男性患者中有62例（52．1％），2组比较差异有统计学意义（P〈0．01）；局部复发率：腹腔内清扫组为16．2％（28／173），腹腔内加腹膜外侧方清扫组为9．6％（21／219），2组比较差异有统计学意义（P〈0．05）；5年生存率：腹腔内清扫组为49．1％（85／173），腹腔内加腹膜外侧方清扫组为59．4％（130／219），2组比较差异有统计学意义（P〈0．05）。结论 低位直肠癌保留神经的腹膜外侧方扩大清扫，可以减少局部复发，提高患者5年生存率，但也会影响患者术后排尿和男性性机能。     

Voiding function and sexual activity in patients following Hautmann neobladder construction

PURPOSE: We retrospectively evaluated the outcome of Hautmann neobladder reconstruction in terms of complications, lower urinary tract symptoms, and sexual function in a large group of patients who underwent radical cystectomy. METHODS: We reviewed the medical records of 118 patients (105 men and 13 women) who underwent radical cystectomy and Hautmann neobladder construction at the Gifu University Hospital or one of its affiliate hospitals between Jan 1993 and Dec 1999. The 118 patients were asked to complete a questionnaire regarding lower urinary tract symptoms and sexual activity, and the data was compiled. RESULTS: The mean follow-up period was 50.4 months (range, 6.8-88.2). Early complications comprised wound infection (in 17.8% of patients) and ileus (in 10.1% of patients). Late complications comprised ileus, pyelonephritis, stone, and stricture of the pouch-urethral anastomosis, each of which occurred in 3.4% of patients. Eighty-one (73 men and 8 women, 72.9%) of 90 surviving patients replied to the questionnaire. Seventy-seven (95.1%) of these patients reported spontaneous micturition, whereas 4 (4.9%) patients required intermittent self-catheterization. The mean total I-PSS was 11.6 points. Twenty-five percent of patients experienced interrupted voiding almost always; 38% of patients did not experience this at all. Approximately 26% of patients experienced weak urinary streams; 36% did not. Daytime continence was achieved in 97.3% of patients; nighttime incontinence was present in 61.3%. Preoperatively, 79.7% of the men were capable of sexual intercourse. Postoperatively, 63.6% of men who underwent radical cystectomy with the nerve-sparing procedure were capable of sexual intercourse, whereas only 14.8% of men who underwent radical cystectomy without the nerve-sparing procedure were. CONCLUSIONS: Morbidity rates were acceptable and functional outcome was excellent in this rather large group of patients who underwent Hautmann neobladder construction. Some problems have not been fully overcome, however, i.e., nocturnal incontinence and sexual dysfunction.